Health inspection·February 21, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet resident's need of medications upon admission for one of three sampled residents (Resident 1). The facility did not administer Resident 1's seven (7) medications due to be given on 1/26/2024 at night (usually scheduled at 9 PM). This deficient practice had a potential of causing a decline in resident's health condition. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted at the facility on 1/26/2024 with the diagnoses that included but not limited to hemiplegia (paralysis of one side of the body), chronic respiratory failure (severe problem in breathing), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and chronic pulmonary edema (water accumulated in the lung). A review of the facility's census list indicated Resident 1 was admitted to the facility on [DATE] at 8 PM. A review of Resident 1's list of medications ordered printed on 2/20/2024, indicated Resident 1's medications were ordered on 1/26/2024 at 11:51 PM. Seven (7) of medications ordered were scheduled to be given as follows: 1. Anoro Ellipta (medication to treat various lung diseases) inhalation aerosol powder 62.5-25 micrograms (mcg, unit of measurement) per activation for COPD. Inhale 1 puff nightly. 2. Coreg 25 milligram (mg, unit of measurement) tablet for hypertension (HTN, high blood pressure). Give 1 tablet by mouth two times a day. 3. Eliquis 2.5 mg tablet for myocardial infarction (MI, heart attack) prophylaxis (prevention). Give 1 tablet by mouth two times a day. 4. Entresto 24-26 mg tablet for HTN. Give 1 tablet by mouth two times a day. 5. Lipitor 80 mg tablet for hyperlipidemia (HLD, a condition in which there are high levels of fat and lipids in the blood). Give 1 tablet by mouth at bedtime. 6. Seroquel 50 mg tablet for depression manifested by sleeping poorly. Give 1 tablet by mouth at Page 1 of 3 055548 055548 02/21/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0755 bedtime. Level of Harm - Minimal harm or potential for actual harm 7. Trintellix 29 mg tablet for depression manifested by feeling helplessness and hopelessness. Give 1 tablet by mouth at bedtime. Residents Affected - Few A review of Resident 1's electronic medication administration record (eMAR) did not indicate documented evidence of the 7 medications (Anoro Ellipta, Coreg, Eliquis, Entresto, Lipitor, Seroquel and Trintellix) were given on 1/26/2024 at night. On 2/20/2024 at 11:06 AM during an interview, the director of nursing (DON) stated Resident 1 was admitted to the facility on [DATE] at 8 PM from a hospital. The DON stated the registered nurse (RN) on duty usually would get a discharge report from the hospital regarding the incoming resident's meal and medication status, and the RN would communicate with the hospital to find out if the resident would have dinner and/or any medications prior to the transfer. On 2/20/2024 at 12:05 PM, during a concurrent record review and interview with the DON, Resident 1's progress note dated 1/26/24 at 9:22 PM was reviewed, the DON stated the progress notes indicated the physician (from the facility) was notified of Resident 1's discharge medication list on 1/26/24; however, the DON stated the nurse did not indicate the time of notification. The DON stated there was no physician's order and no documentation that a physician had approved omitting Resident 1's nighttime medication (Anoro Ellipta, Coreg, Eliquis, Entresto, Lipitor, Seroquel and Trintellix) that was supposed to be due at the night of 1/26/24 and after the resident was admitted to the facility. On 2/20/2024 at 1:37 PM, during an interview and a concurrent review of the Warm hand off - hospital to Skilled nursing Facility (SNF) for Resident 1, the DON stated the document did not mention Resident 1's nighttime medication. In addition, the DON stated the facility did not have a policy that address or have a process in place for residents' medication needs upon admission. On 2/20/2024 at 1:47 PM during an interview, the DON reviewed Resident 1's General Acute Care Hospital's (GACH) After Visit Summary (given to patients after medical appointments to summarize their health and guide future care) under medical list with print date of1/26/2024 at 3:37 PM, the DON stated Resident 1 had evening or nighttime medications that were due on 1/26/24 at 9 PM, after Resident 1's admission to the facility; those medications that should have given were: 1. Anoro Ellipta) inhalation aerosol powder 62.5-25 micrograms (mcg, per activation for COPD. Inhale 1 puff nightly. 2. Coreg 25 milligram (mg, unit of measurement) tablet for hypertension (HTN, high blood pressure). Take 25 mg two times a day (Last time given in GACH on 1/26/2024 at 8:15 AM). 3. Eliquis 2.5 mg tablet for myocardial infarction (MI, heart attack) prophylaxis (prevention). Take 1 tablet by mouth two times daily (Last time given in GACH on 1/26/2024 at 8:15 AM). 4. Entresto 24-26 mg tablet for HTN. Take 1 tablet by mouth two times daily (Last time given in GACH on 1/26/2024 at 8:15 AM). 5. Lipitor 80 mg tablet for hyperlipidemia (HLD, a condition in which there are high levels of fat and lipids in the blood Give 80 mg by mouth nightly. 055548 Page 2 of 3 055548 02/21/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0755 6. Seroquel 50 mg tablet for depression manifested by sleeping poorly. Take 50 mg by mouth nightly. Level of Harm - Minimal harm or potential for actual harm 7. Trintellix 29 mg tablet for depression manifested by feeling helplessness and hopelessness. Take 20 mg by mouth nightly. Residents Affected - Few On 2/20/2024 at 1:48 PM during an interview and a concurrent review of Resident 1's eMAR dated 1/2024, the DON stated Resident 1 did not receive the evening doses of the 7 medications (Anoro Ellipta, Coreg, Eliquis, Entresto, Lipitor, Seroquel and Trintellix) due on 1/26/2024 after Resident 1's admission. The DON stated, missing doses could lead to a decline in health conditions. The DON stated if the medications are not in the emergency drugs supplies (E-Kit, a small quantity of medications that can be dispensed when pharmacy services is not available), the nurse should contact the pharmacy for special delivery and notified the physician for possible alternatives. On 2/20/2024 at 1:50 PM, the DON stated there was no documented evidence that the admitting nurse notified the Resident's physician about the 7 medications (Anoro Ellipta, Coreg, Eliquis, Entresto, Lipitor, Seroquel and Trintellix) would be late for Resident 1, or that Resident 1 might miss the evening/nighttime orders and/or doses on 1/26/2024. A further review of Resident 1's progress notes, dated 1/26/2024 to 1/31/2024, did not indicate the facility had contacted the physician regarding the missed doses. A review of the facility's policy and procedure, admission Assessment (dated 10/1/2012), did not include assessment for immediate medication needs or medications that may be due soon around admission time. 055548 Page 3 of 3